Federal Ministry of Health HIV risk factor screening and Counseling form

Name: __________________________________ DOB: ___/___/___ Age: ________ Individual ID: _____________

Date (use dd/mm/yyyy form)

Risk factor assessment Questions
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Do you have history of STD? (Y/N)        

Do you have history of TB? (Y/N)        

Do you have history of multiple sexual partners? (Y/N)        

Is the client among priority targets for HIV testing? (Y/N)
Targets:
1. Widowed
2. Divorced
3. TB patients
4. STI cases
5. Prisoners
6. Orphans and vulnerable children
7. Sexually active high school and university students
8. Discordant couples
9. Uniformed Forces
10. HIV exposed children/contacts/ family index cases
11. Individuals with medical indications or suggestive signs & symptoms of HIV
12. Most at risk population (Female Sex Workers , daily laborers , long distance truck
drivers)
13. Other (specify)

Interpretation:
 If the answer is YES to any of the above questions classify the client as at risk        
and if testing is possible test the client or refer.
 HIV Counseling,Testing and Referral Form

Pre-Test HIV Test HIV Test Post-test Received Referral Reason Point/Place of
Feedback
Date Counseling Accepted Result (R or Counseled HIV Test made? for Testing was Remarks
given
Offered (√) (√) NR or I) (√) Result (√) (Y/N) referral conducted
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Anti-Retroviral Therapy (ART) follow-up form

Any
Currently Properly Defaulted
Unique related Referral Reason
Individual ART Start on ART taking Counseling from Referral
ART Date of visit health MUAC made? for
ID Date medication ART (Code) ART Feedback
No. problem (Y?N) referral
(Y/N) (Y/N) (Y/N)
identified

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